There is little consistency in how severe mental illness (SMI) is defined in practice, and no operational definitions.

To test two operationalised definitions, based on the National Institute of Mental Health (1987) definition: the first uses three criteria (diagnosis of psychosis; duration of service contact ≥ 2 years; GAF score ≤ 50), the second only the last two.

Annual prevalence rates of SMI in two European catchment areas for each criterion and the criteria combined were calculated.

The first definition produced rates of 2.55 and 1.34/1000 in London and Verona, respectively; the second permitted an additional 0.98/1000 non-psychotic disorders to be included in Verona.

The three-dimensional definition selects a small group of patients with SMI who have psychotic disorders. The two-dimensional approach allows estimates of SMI prevalence rates which include all forms of mental disorder.

Family interventions for schizophrenia have proved to be highly effective in preventing relapse, but it is not clear how they work or how they should be structured.

To examine the effects of a behavioural family intervention and a family support programme on communication, problem solving and outcome in order to determine the impact of structured communication training.

Patients and family members participating in the Treatment Strategies in Schizophrenia study were videotaped engaging in 10-minute problem-solving conversations at baseline and after the conclusion of the family intervention. Tapes were subsequently evaluated for changes in communication patterns.

The intensive behavioural intervention did not produce differential improvement in communication, and change in communication was unrelated to patient outcomes.

The data suggest that intensive behavioural family interventions may not be cost efficient, and that change in family communication patterns may only be important for a subset of families.

There is little available literature on the effect of suicide methods on brain weight.

To explore variations in postmortem brain weight in different methods of fatal self-harm (FSH) and in deaths from natural causes.

A review of a sample of coroners' records of elderly persons (60 and above). Verdicts of suicide, misadventure and open verdicts were classified as FSH. Post-mortem brain weight for 142 FSH victims and 150 victims of unexpected, sudden or unexplained death due to natural causes, and from various methods of FSH, were compared.

Brain weight of victims of FSH was significantly higher than of those who died of natural causes (P<0.01); brain weights in both groups were within the normal range for this age group. There was no significant difference in brain weight between different methods of FSH (P>0.05).

The findings require critical examination and further research, to include data from younger age groups. A regional or national suicide neuropathological database could be set up if all victims of FSH underwent routine neurohistochemical post-mortem examination.

Deteriorating cognitive function in late life substantially increases the risk for dementia, for other non-cognitive morbidity, for dependency, and early death.

To identify early predictors of late-life cognitive outcome.

Cognitive function, premorbid IQ, and cardiovascular risk exposure were recorded on 1083 subjects on entry to a hypertension treatment trial in 1983–1984. We followed up this cohort 9–12 years later to assess cognitive function with the Mini-Mental State Examination (MMSE), to update exposure status, and to obtain genomic material. Multivariate analysis was used to identify independent baseline predictors of cognitive outcome 9–12 years later.

We followed up 387 subjects (58.6% of survivors). After adjusting for baseline cognition, poorer cognitive outcome was found to be independently associated with a family history of dementia, increasing age, less decline in systolic blood-pressure, lower premorbid IQ (rather than limited education), and abstinence from alcohol.

Reduction in systolic blood pressure (among hypertensives) and moderate alcohol intake could protect against cognitive deterioration in late life.

Information on survival and cause of death in pre-senile dementia is scarce and the organisation of services controversial.

To study survival, place of death and death certification in pre-senile dementia.

Patients aged 45–64 were identified from hospital and community sources in the Northern health region (1985–89) and classified as having pre-senile dementia of Alzheimer type (PDAT) or pre-senile vascular dementia (PVD) by applying an algorithm to case notes. Deaths were ascertained from the National Health Service Central Registry (NHSCR) to 31 December 1998. Survival analysis was performed using the SPSS/PC program, and expected survival calculated from life tables.

Median survival time from diagnosis was 6.08 years and did not differ significantly in PDAT and PVD, or by age or gender; 19.3% of deaths occurred at home, 24.5% in nursing or residential homes and 56.3% in hospital; 72.4% of the death certificates mentioned dementia or Alzheimer's disease; 15.4% were still alive.

Pre-senile dementia has a variable but usually chronic course, requiring appropriate planning and services.

About 30% of psychiatric out-patients with major depression demonstrate partial remission.

To explore whether the addition of cognitive therapy (CT) had any differential effect on residual symptoms or social adjustment.

Patients with residual symptoms of major depression (n=158) were randomised to receive clinical management (CM) alone, or CM plus 18 sessions of CT. Subjects' depressive symptoms and social functioning were assessed regularly over 16 months.

The addition of CT produced statistically significant differential effects on: two out of four measures of overall severity of depression; specific psychological symptoms (guilt, self-esteem and hopelessness); and social functioning (including dependency, interpersonal behaviour and friction).

In patients showing only partial response to antidepressants, the addition of CT produced modest improvements in social and psychological functioning. The implications for research on the mechanisms of action of CT are discussed.

Although road traffic accident injury is the most common cause of traumatic brain injury, little is known of the prevalence of psychiatric complications or the significance of unconsciousness and amnesia.

To describe amnesia and unconsciousness following a road traffic accident and to determine whether they are associated with later psychological symptoms.

Information was obtained from medical and ambulance records for 1441 consecutive attenders at an emergency department aged 17–69 who had been involved in a road traffic accident. A total of 1148 (80%) subjects completed a self-report questionnaire at baseline and were followed up at 3 months and 1 year.

Altogether, 1.5% suffered major head (and traumatic brain) injury and 21% suffered minor head injury. Post-traumatic stress disorder (PTSD) and anxiety and depression were more common at 3 months in those who had definitely been unconscious than in those who had not, but there were no differences at 1 year.

PTSD and other psychiatric complications are as common in those who were briefly unconscious as in those who were not.

Few studies of suicide have simultaneously examined the individual and combined effects of psychosocial and psychiatric risk factors.

To do so in a representative sample of suicides.

A case-control psychological autopsy was conducted among 113 consecutive suicides and 226 living controls matched for age, gender, ethnicity and area of residence inTaiwan.

Five major risk factors (loss event, suicidal behaviour in first-degree relatives, ICD–10 major depressive episode, emotionally unstable personality disorder and substance dependence) were found to have independent effects on suicide from multivariate conditional logistic regression analysis.

Effective intervention and management for loss event and major depressive episode among emotionally unstable subjects with a family tendency of suicidal behaviour, frequently also comorbid with alcohol or other substance dependence, may prove to be most effective for suicide prevention in different populations.

Seasonal variation in suicidal death has been observed in many countries. In particular, a cyclic variation was found for both men and women in England and Wales in the 1960s and 1970s. Men showed a single 12-month cycle whereas women showed two cycles.

To re-examine the seasonal variation in suicides in England and Wales for the period 1982–1996.

A harmonic analysis was used to detect the seasonality of the suicide data.

The seasonal effect on suicide is greatly diminished in England and Wales. This is shown by the reduced amplitude and smaller proportion of variance accounted for by the season.

The seasonal effect on suicide has either diminished or vanished.

Patients with depression are often not prescribed antidepressants for an adequate period of time.

The impact of antidepressant prescribing patterns on the risk of relapse or recurrence of depression is examined.

The Medi Plus UK Primary Care Database was used to identify patients treated for depression with a selective serotonin reuptake inhibitor (SSRI). Records were used to construct hierarchical prescription patterns (less than 120 days, switching/augmentation, upward titration, or stable use) as indicators for the occurrence of relapse or recurrence of depression.

Patients with stable use experienced the lowest risk of relapse or recurrence. Factors significantly associated with increased risk include prior use of anxiolytic medications, more comorbid conditions and younger age.

The SSRI prescription pattern most consistent with recommended depression treatment guidelines was associated with the lowest risk of relapse or recurrence.

Previous studies have found that the reliability of the lifetime prevalence of bulimia nervosa is low to moderate. However, the reasons for poor reliability remain unknown.

We investigated the ability of a range of variables to predict reliability, sensitivity, and specificity of reporting of both bulimia nervosa and major depression.

Two interviews, approximately 5 years apart, were completed with 2163 women from the Virginia Twin Registry.

After accounting for different base rates, bulimia nervosa was shown to be as reliably reported as major depression. Consistent with previous studies of major depression, improved reliability of bulimia nervosa reporting is associated with more severe bulimic symptomatology.

Frequent binge eating and the presence of salient behavioural markers such as vomiting and laxative misuse are associated with more reliable reporting of bulimia nervosa. In the absence of the use of fuller forms of assessment, brief interviews should utilise more than one prompt question, thus increasing the probability that memory of past disorders will be more successfully activated and accessed.

Treatments in different settings have different costs. A dilemma arises if expensive treatments lead to better outcomes.

To investigate conflicts between the priorities of cost minimisation, clinical effectiveness, and cost-effectiveness in the detoxification of opiate addicts.

Cost and clinical effectiveness were examined using published outcome data. The main outcome measures were: achieving a drug-free state on completion of detoxification; the economic costs of treatment.

In terms of simple cost, in-patient detoxification is much more expensive than out-patient treatment (ratio, 24:1). With adjustment for successful outcome, the costs are almost identical (ratio, 0.9:1). Comparison of specialist and general psychiatry in-patient settings showed that even when adjusted for clinical outcomes, the specialist setting is more costly (ratio, 1.9:1), although the outcomes are better.

Naïve adherence to cost and cost-containment considerations is dangerous. Discussion of treatment costs is misleading if not informed by, and adjusted for, evidence of effectiveness. This is especially important where marked differences in outcome between treatment options exist.

Gender is one of the most frequently replicated predictors for suicide.

To identify risk factors for suicide among males and females and to investigate whether risk factors for suicide differ by gender.

A time-matched nested case–control design was performed using Danish longitudinal register databases to obtain 811 suicide cases and 79 871 controls. Data were analysed using conditional logistic regression.

A history of hospitalised mental illness was the most marked risk factor for suicide for both genders. Unemployment, retirement, being single and sickness absence were significant risk factors for men, whereas having a child <2 years old was significantly protective for women. The relative risks for suicide differed significantly between genders according to psychiatric admission status and being the parent of a child < 2 years. However, adjustment for these factors did not eliminate the gender difference in suicide risk.

Risk factors for suicide differed by gender and gender differences could not be explained by differential exposure to known risk factors.

Previous studies suggest that brain serotonin neurotransmission may mediate the actions of lithium carbonate. Acute tryptophan depletion reduces brain serotonin and allows the study of this neurotransmitter in patient groups.

To examine the effects of acute tryptophan depletion on mood and suicidal ideation in bipolar patients who were symptomatically stable on lithium.

Nineteen subjects satisfying DSM–IV criteria for bipolar I disorder participated in a within-subject, double-blind, placebo-controlled random-order crossover study. Symptoms were evaluated following acute tryptophan depletion, which was induced by a 100 g amino acid drink following an overnight fast.

Plasma tryptophan fell significantly after the depleting drink, but not after the control drink (P < 0.05, paired t-test, mean reduction 83%). No significant changes in mood or suicidality scores were recorded after acute tryptophan depletion.

Acute tryptophan depletion does not reverse lithium's effects on mood and suicidality in bipolar disorder.

Neuroimaging studies of major depressive disorder (MDD) indicate interhemispheric differences in prefrontal cortical activity (right greater than left).

To investigate whether there are any interhemispheric differences of motor cortical excitability in MDD.

Eight patients with treatment-refractory MDD off medication were assessed for the severity of their depression, and transcranial magnetic stimulation studies (bilateral motor threshold and paired-pulse studies) were conducted. Eight normal controls were also studied.

MDD patients showed significant interhemispheric differences in motor threshold and paired-pulse curves, both of which showed lower excitability on the left hemisphere. Such differences were absent in controls.

Our findings may aid the further understanding of the neurophysiology underlying MDD.

In people with learning disability one of the most frequent reasons for psychiatric referral is challenging behaviour.

To determine what proportion of people with challenging behaviour actually have psychiatric symptoms.

Using an instrument specifically designed for use by informants, a sample of 320 people with administratively defined learning disability, with and without challenging behaviour, was surveyed for the presence of psychiatric symptoms.

Increasing severity of challenging behaviour was associated with increased prevalence of psychiatric symptoms, depression showing the most marked association. Anxiety symptoms were associated with the presence of self-injurious behaviour.

There is clearly the potential for reducing challenging behaviour by improved identification and treatment of coexisting psychiatric disorders. The possibility of modifying diagnostic criteria for depression in people with learning disability, by including aspects of challenging behaviour, merits attention.

Low cholesterol may act as a peripheral marker for parasuicide.

To examine the relationship between total serum cholesterol and psychological parameters in parasuicide.

Total serum cholesterol and self-rated scores for impulsivity, depression and suicidal intent were measured in 100 consecutive patients following parasuicide, pair-matched with normal and psychiatric control groups.

Backward, stepwise multiple regression analysis revealed a significantly lower mean cholesterol in the parasuicide population (P<0.01). Across all groups there was an independent significant (P<0.01) negative correlation between cholesterol and self-reported scores of impulsivity. No correlation existed between cholesterol and scores for depression or suicidal intent.

The data confirm previous reports of low cholesterol in parasuicide. This is the first reported investigation of the construct of impulsivity in relation to cholesterol. We hypothesise that the reported increased mortality in populations with low cholesterol may derive from increased suicide and accident rates consequent on increased tendencies to impulsivity in these populations.

It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs.

To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event.

This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant.

Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P < 0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline.

Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.

The York resource allocation formula includes a calculation of the amount needed to purchase mental health services equitably in each health authority in England. However, the amount which is actually spent on services is at the discretion of the authority.

To compare expenditure on mental health services with allocation, and test the hypothesis that differences between them are to the disadvantage of services in deprived areas.

A comparison of routine expenditure and allocation data, and linear regression modelling of the ratio of expenditure to allocation.

The ratio of expenditure to allocation varies widely. Relative underspending occurs more frequently in deprived areas, although not in the four inner-London health authorities.

The intentions of the York formula are not achieved in practice. The implications of the formula for mental health should be made explicit to health authorities, and shortfalls in mental health expenditure relative to allocation should be justified at a local level.